What to Know About Breast Surgery and Insurance
Breast surgery isn’t typically a decision someone makes on a whim. In fact, plastic surgeons discourage that. The main reason is that breast procedures are major surgeries that can impact a person both physically and mentally. They also aren’t typically covered by insurance, which can result in a significant cost for the patient. However, there are a few exceptions. Here, leading plastic surgeons explain which breast procedures are covered by insurance and which ones aren’t. This is everything to know about breast surgery and insurance, so you can be prepared before your consultation.
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Is Cosmetic Breast Surgery Covered by Insurance?
Chicago plastic surgeon Michael Horn, MD says cosmetic breast surgery, such as breast augmentation with breast implants or breast lifts, is not covered by insurance. Therefore, the patient is responsible for the cost. “Before scheduling a plastic surgery consultation, you should always find out beforehand if the doctor accepts insurance as payment for the type of breast surgery you are interested in,” adds Tucson, AZ plastic surgeon Raman C. Mahabir, MD. “That is, while also keeping in mind that cosmetic breast surgery is not covered by insurance.”
Is Breast Reduction Surgery Covered by Insurance?
Miami plastic surgeon Sean Simon, MD says, “Breast reduction surgery was more commonly covered by insurance in the past, but may still be covered if certain conditions are met. The patient’s consultation should document specific issues associated with macromastia, or very enlarged breasts. These are heavy, pendulous breasts that are often associated with back, shoulder and neck discomfort. They can also cause difficulty with certain physical activities and clothing fitting properly.”
To be considered for coverage for a breast reduction, it is important for surgeons to document these issues. “Other signs that the plastic surgeon should pay attention to and document include the condition of the skin. Are there are stretch marks? Are there rashes and irritations caused by moisture and humidity that typically builds up under the breasts? We also look for bra-strap grooving on the shoulders. These are marks on the shoulders from the high tension and pressure from bra straps. And, we document any asymmetry of the breasts. All this information is useful for the insurance company.”
Pasadena, CA plastic surgeon Lily Lee, MD adds that most insurance companies will publish their policy criteria online. “When determining if a patient is covered, they want to know that the patient has exhausted all nonsurgical options first,” she explains. “These include physical therapy, weight loss, rash management, etc. The insurance companies also have a minimum resection weight requirement, which is calculated based on the patient’s Body Surface Area (BSA). How much of the breast that is resected is not determined by me, the surgeon. In my practice, we will calculate that weight and I will give the potential patient a breast implant with similar weight to hold. I ask them, are you OK losing this much from each breast? If so, then we have a good insurance candidate.”
What to Ask Your Insurance About Coverage for Breast Surgery
Dr. Simon says patients should reach out to their insurance carrier first to see if coverage is even possible before consulting with a surgeon. “For a breast reduction, I always advise patients to speak with the customer support or patient advocate rep from their insurance company prior to scheduling surgery.” That way no one gets their hopes up only to find out that they have to pay out of pocket. “Please keep in mind that many plastic surgeons do not accept insurance, but out-of-network reimbursement may defray some of the costs of surgery,” adds New York plastic surgeon B. Aviva Preminger, MD. “And, insurance may cover the operating room and anesthesia portions of the procedure.” It’s important to confirm these points with both your prospective surgeon and your insurance company.
Though cosmetic breast surgery isn’t covered by insurance, a breast implant rupture or capsular contracture may be treated differently. “Ask your insurance company if they will cover it,” says Dr. Preminger. “However, keep in mind that while the companies may cover the implant removal, they rarely pay for implant replacement.”
Breast Reconstruction Surgery: What Insurance Covers
“Breast cancer–related procedures are required by law to be covered by insurance companies,” says Dr. Preminger. “This includes surgery for those who choose to have prophylactic mastectomies for a genetic predisposition to develop breast cancer such as BRCA.” According to information published in The Breast Reconstruction Guidebook, which is also provided on Breastcancer.org, breast reconstruction procedures should be covered by your health insurance plan, whether they are done right away, soon after mastectomy/lumpectomy, or many years later. This includes procedures that may be needed over time to refine the reconstruction and/or to create symmetry between the breasts.” Dr. Simon says these can include nipple reconstruction as well.
Per the Guidebook, the Women’s Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. In addition, Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state. Government- and church-sponsored plans are not necessarily required to cover reconstruction. Therefore, you may need to check with your plan administrator. Even if you’re covered, it’s still possible to run into problems, especially in certain situations. For example, maybe you’ve chosen a newer type of reconstructive procedure, you’re having surgery to create a more balanced appearance. Coverage can also be an issue if you want to use a plastic surgeon who is outside your plan’s network. It’s always best to communicate with your insurance provider up front and check on what exactly is covered. This helps you avoid the work of trying to get payment later.
